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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address Y } !>; , V 6 City •Lot Size PM <br /> 6 Z <br /> Owner's Name ■u'tc K 0 1 S 0 1 �< < S Addressf7 S `t a 0<� Phone 7 <br /> 'Contractor's Name ��� +� �icense No. _/ q 3 `Z - Phone o <br /> TYPE OF WELL/PUMP.a...� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL —PROBLEMAREA -CONSTRUCTION SPECIFICATIONS $ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ i Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION JC INo septic system permitted if public sewer is <br /> vailable within 200 feet.! <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms 31, <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT. © ''' ' Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE i ❑ No. &�Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I ❑ Depth I Size! Number I <br /> SUMPS ❑ Distance to nearest: ; Well! Foundation Property Line <br /> DISPOSAL PONDS 1 ❑ 1 ✓ <br /> I hereby certify that I have prepared this'applicati9p and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local hiValth District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." is <br /> The applicant c 'for alhre u'i ' spection Co to drawing on reverse s de. <br /> Date: 1,3 <br /> Signed Title:.�Cl•KL!I� <br /> i FOR DEPARTMENT USE ONLY 1 <br /> Application Accepted by wr""�- ` -� Date `lArea <br /> 41 <br /> Pit or Grout Inspection by Date Final Inspe qtion by <br /> Additional Comments: <br /> ❑ Stk 4664781 ❑ Lodi 3621 ❑ Manteca 823- ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CAK RECEIVED BY DATE PERMIT"NO. <br /> INFO CAS H <br /> +EH 13-24(REV.10/831 4�3c .c,>oad&-y <br /> -� <br /> tH 14-28 <br />